Obstetrics and Gynaecology Flashcards
Antenatal history taking
- age, gestation, BMI
- gravidity and parity
- previous births - dates, gestation, weight, delivery, any complications
- fetal movements (from 20 weeks), pain, PV loss, bleeding
- all other history
Antenatal testing
Routines:
12 week dating/booking scan - nuchal translucency for structural abnormality also
20 week anomaly scan
- check fetal growth, number of babies and placental site
- blood group, Hb and rhesus status
- height and weight
- urine (UTIs need to be treated)
Additional screening:
- 8-12 week - infectious disease/BBVs, sickle cell, thalassaemias
- 11-14/40 - combined blood test for T18, T13, T21 (Edward’s/Patau’s/Down’s) (1/150 is high risk) - no later
- 18-21/40 - structural abnormalities
Obstetric examination
- well/unwell - appearance, pulse (10-20bpm faster), BP (lower), temp, resp rate, sats
- normal hyperpigmentation (linea nigra, striae gravidarum)
- symphysis fundal height - 20 weeks at umbilicus + 1cm for every weeks gestation
- palpate masses (foetus/bladder) and tenderness
- activity? foetal movements, auscultate heart, CTG
- liquor volume
Foetal palpation
FLAPPES
Fundus
Lie (longitudinal/transverse/oblique relation of spinal columns)
Attitude (relation of feotus to itself, flexion of limbs)
Presentation (cephalic/breech/arm/compound)
Position (OA, OT, OP)
Engagement (0/5 = no head palpable above pelvic brim, engaged, 5/5= completely above brim)
Summary
Causes of large or small bump for dates
Big - SFH > dates
- multiple pregnancy
- polyhydramnios
- large BMI
- fibroids
Small - SFH < dates
- IUGR or SGA
- low BMI
- dates incorrect
Folic acid in pregnancy
Oral, >1month before conception until week 12, to protect against neural tube defects
400 micrograms OD - normal singleton
5mg OD
- multiple pregnancy
- sickle cell disease
- previous pregnancy with neural tube defect
- diabetes
- taking anti-epileptic medication
SGA vs IUGR
SGA = below 10th centile
IUGR = growth slowing or ceasing
- not all IUGR are SGA
Causes of IUGR
Symmetrical (body proportional), early onset
- idiopathic
- chromosomal
- maternal drugs/smoking/alcohol
- maternal nutritional deficiency
- TORCH infections - toxoplasmosis, other (syphilis, varicella-zoster, parvovirus B19), rubella, cytomegalovirus, herpes
Asymmetrical (brain sparing), later onset
- utero-placental deficiency
- pre-eclampsia/HTN
- renal/cardiac disease
- multiple gestation
Risk factors for SGA
- age >40
- smoker (10+)
- cocaine use
- daily vigorous exercise
- previous SGA or stillborn
- maternal or paternal SGA
- HTN, diabetes or vascular disease
- renal impairment
- antiphospholipid syndrome
- BMI <20
- pregnancy interval <6 months or >30 months
Investigations for SGA/IUGR
- doppler USS
- detailed foetal anatomical survey and uterine artery doppler
- karyotyping if severe SGA + structural abnormalities
- serological screening for congenital CMV and toxoplasmosis
- testing for syphilis and malaria if high-risk
Two weekly scanning! Don’t deliver early unless restricted blood flow - do everything possible to keep to term.
Perineal tears
5-10% of first births
1st degree - only skin
2nd degree + perineal muscles (most common)
3rd degree + anal sphincter
4th degree + rectum
Stages of labour
Latent phase
- < 4cm dilated
- cervix effacing and thinning
- irregular tightenings
First stage
- 4-10cm dilated
- cervix effaced
- contractions regular and painful
- 8 or 5 hours
Second stage
- fully dilated, feel need to push
- active pushing -> baby born
- <3 or 1 hours
Third stage
- delivery of placenta and membranes (check for completeness)
- use IV syntometrine a few mins after birth, controlled cord traction
APGAR scoring
Done at 1, 5 and 10 mins
Score /10, each category /2
Heart rate Respiratory effort Muscle tone Response Central colour
Prescribing in pregnancy
- beware risk women stopping regular meds as fear risk
- but usually need extra dose - as increased plasma volume, higher metabolism, increased renal clearance
- may need extra monitoring of mum and baby
- NO drug is completely safe in pregnancy, but well mum = well baby
- MDT prescribing if complex
Drugs to NEVER prescribe in pregnancy
Methotrexate
Radioactive iodine
Lithium
Roaccutane
Types of vaginal bleeding in pregnancy
Spotting
Minor haemorrhage<50ml
Major haemorrhage 50-1000ml, no signs of clinical shock
Massive haemorrhage >1000ml, signs of clinical shock
Early pregnancy <20 weeks
- ectopic, miscarriage
Late pregnancy = antepartum haemorrhage
- placenta praevia, placental abruption
Post-partum haemorrhage (>500ml)
+ vaginitis, trauma, mucus show, uterine rupture, fibroid degeneration or torsion at any stage
Miscarriage types and causes
1/5 pregnancies, defined as <24 weeks.
Threatened miscarriage = vaginal bleeding in early pregnancy (50% continue pregnancy). Mild PV bleeding and closed os.
Inevitable miscarriage = PV bleeding more severe and os open
Missed miscarriage = gestational sac with or without fetus, but no FH. Os remains closed (fetus retained)
Incomplete miscarriage = most products already passed
Recurrent miscarriage = 3 or more consecutive miscarriages, with or without known cause
Causes
- mostly genetic abnormalities
- maternal diabetes/thyroid disease
- phospholipid/SLE
- uterine abnormalities
- cervical incompetence
Miscarriage investigations
- history - LMP, pain, bleeding
- A-E exam - ensure not haemodynamically shocked
- abdo exam
- speculum - cervical state, tissue in os?, amount of bleeding
- USS - abdo will show viable foetus from 6.5 weeks, transvaginal from 5.5 weeks
- serum hCG (doubling/halving time 2 days) - will stay positive a few days after losing foetus
- if significant bleeding - blood and rhesus group, FBC, G+S, admission
- psychological support
Miscarriage management
Expectant
- if stable, apyrexic, uncomplicated
Medical
- if missed/incomplete
- give oral or vaginal misoprostol
Surgical
- if missed/incomplete and choice, or if failed medical/conservative management
- evacuation of uterus with or without GA, products sent for histology
Placenta praevia
- should always be found on USS, but may present with painless fresh bleeding
- minor-major - 2cm away/completely covering os
- avoid PV exams and sex
- C section at 36-8 weeks (unless minor and head below placenta)
Risk factors
- previous termination
- previous surgery - caesarean, myomectomy
+ older age, previous praevia, multiparity, multiple pregnancy, smoking
Placental abruption
- presents as pain, maybe to shoulder tip, tense woody uterus maybe expanding in size, maybe loss of FMs
- concealed if no bleed, revealed if apparent haemorrhage
- needs immediate delivery by C section unless mum and baby both well and ?partial abruption - admit and monitor
Usually from trauma, increased risk in smoking, cocaine, HTN, previous abruption, FGR, malpresentation, polyhydramnios, multiparity, increased age, low BMI
Placenta accreta
- abnormally invasive adherent placenta will likely cause heavy bleeding during delivery
- risk after myometrial damage (surgeries/ablations)
- recommend caesarean hysterectomy at 34-36 weeks
Post-partum haemorrhage
> 500ml
Primary <24 hours, Secondary 24hrs-12 weeks
PPPH:
TONE - 70%, need uterotonics eg syntometrine
TRAUMA - of any organ
TISSUE - retained placenta/membranes, need EUA
THROMBIN - maternal bleeding disorder
Risk factors:
- previous PPH, abruption, anaemia, episiotomy, physiological 3rd stage, multip, emergency delivery, instrumental, APH, IOL, high BMI, long labour, HTN, older age
Hypertension in pregnancy
HTN = systolic ≥140 ± diastolic ≥90 Severe = systolic ≥160 ± diastolic ≥110
Chronic HTN if before 20 weeks
Gestational HTN if presenting after 20 weeks without proteinuria
Pre-eclampsia if after 20 weeks with proteinuria
Eclampsia if convulsions
More likely if diabetic, CKD, autoimmune disease, primip, older age, high BMI, long pregnancy interval, multiple pregnancy, past hx
Treatment - low dose 75mg aspirin from 12 weeks-delivery. Monitor for headache, RUQ pain, vision change, foetal movements, oedema. Regular urinalysis for protein.
Pre-eclampsia
= >30g/dL protein in urine, new bp ≥140s or ≥90d after 20 weeks
- when inadequate invasion to spiral arteries of placenta, increased resistance, less blood flow - affects mum and baby!
- if suspected needs admission - regular bp checks, 24hr urine collection
Complications:
- brain - haemorrhage, eclampsia, anoxia -> cardiac arrest
- lungs - PE, pulmonary oedema, aspiration pneumonia following fit
- liver - HELLP (haemolysis elevated liver low platelets), capsular rupture, necrosis/failure
- blood - PPH, DIC
- kidneys - renal failure, hyperkalaemia
- foetus - IUGR, abruption, death
Management of pre-eclampsia
1st - labetalol (unless asthma)
2nd - nifedipine
Alternative - methyldopa
Baby is unlikely to go to term - give steroids / MgSO4
- balancing risk of prematuity vs pre-eclampsia
VTE risk - give TEDs and LMWH
If emergency (increased bp, severe headache, flashing lights, oedema, hyperreflexia - central haemorrhage probable) stabilise mum before considering delivery , using labetalol, hydralazine, nifedipine, MgSO4 infusion, then LSCS when stable. Keep in hospital until 5 days postpartum.
Take aspirin in future pregancies!
Malpresentation
At term, 3-4% (commoner earlier)
- transverse lie
- oblique lie
- breech - front, complete, footing
- compound presentation
Causes:
- fetal abnormality
- liquor volume
- low lying placenta
- uterine abnormality (bicornucate)
Management
- ECV from 36/40 primip (40% success), 37/40 multip (60% success) - only after detailed USS and CTG
- if unstable lie, ECV then immediate ARM
- tocolysis uterine relaxant before
- need anti-D if Rh-ve
- NO ECV if in labour, uterine abnormality, fetal compromise, ruptured membranes, multiple pregnancy, vaginal bleeding
- Caesarean always recommended, at 39 weeks
- Vaginal delivery possible, likely episiotomy, late pushing. IV access, G+S, no epidural advised, no syntocinon, neonatologist present at delivery
Preterm birth
- low birth weight <2.5kg, very low <1.5kg. ICU offered from 23-24 weeks, warn of extreme disability risk.
- more likely SENs, mortality risk throughout childhood
- increased vulnerability - functionally/structurally immature organ systems, poorer immune system, hypoxia/ischaemia/inflammation
Immediate problems
- temperature control - humidified incubator
- infection/inflammation - low IgG, poor skin/mucosal barrier, lack of adaptive immune response, invasive treatments
- respiration - RDS - give oxygen maybe with pressure support, maybe surfactant down ETT
- CVS
- fluid balance and electrolytes - daily weights
- nutrition - TPN through central line until established feeds - breast milk!!
- GI tract - can’t suck swallow and breathe until 34-35 weeks, use NG, slow introduction of feeds
- retinopathy - avoid sats >95%
Multiple pregnancies diagnosis and added risks
Seen on 12 week USS
- DCDA most common - non-identical related to IVF
- MC identical, risk TTTS as shared placenta, MCMA deliver at 32 weeks
Risks:
- anaemia - take FBC at 20, 28 and 34 weeks, treat with ferrous sulfate 200mg BD if Hb<11.5
- congenital malformation - 5mg folic acid and screening
- preterm labour (most)
- HTN and pre-eclampsia - aspirin given if any other risk factors, BP and urinalysis at every visit
- FGR
- TTTS - treat with labour ablation of connecting vessels in utero (specialist) or one or both babies will die (one donor malnourished, one recipient engorged risking HF)
- stillborn (most likely with MC)
Monitoring and delivery of multiple pregnancies
Twins annotated on first scan and track growth individually
DCDA - growth scans every 4 weeks from 24 weeks, elective delivery at 37-38 weeks
MCDA - growth scans every 2 weeks from 16 weeks, elective delivery at 36-27 weeks
Vaginal birth if uncomplicated and twin 1 is cephalic - but warn increased risk of morbidity for 2nd twin on delivery, and risk of C section for 2nd
LSCS if not cephalic
VTE risk in pregnancy
VTE risk x6 in pregnancy, x10 by caesarean
- more factors VII, VIII, X
- more fibrinogen
- venous stasis in lower limbs
- reduced protein S activity
- reduced endogenous anticoagulant factors
- suppressed fibrinolysis
+ added risk if smoker, older age, medical (diabetes/SLE/cancer), immobility (PROM, travel), pre-eclampsia, dehydration, long labour, IVDU, surgery, PPH, thrombophilia, previous VTE, FHx
- never do D dimer in pregnancy as will be elevated anyway with coag changes!
- treat with LMWH BD, dose based on booking weight (beware half life increases as pregnancy progresses)
Anaemia in pregnancy
Hb <105g/L
- steep physiological fall at 20 weeks
- monitored at booking and at 28 weeks (+ in black patients test sickle-cell)
- iron deficiency = low MCV, folate deficiency = raised MCV
- more likely if previous anaemia, poor diet, or if frequent/multiple pregnancy
- predisposes to PPH, infection, worsening HF
- treat with ferrous sulfate 200mg BD PO alternate days or twice weekly
Diabetes care in pregnancy
Preconception - avoid unplanned pregnancy, need to optimise insulin control, give 5mg folic acid, dietician review, stop oral hypoglycaemics statins and ACEi, retinopathy and nephropathy screen.
Antenatal - regular home monitored glucose, regular review of insulin (needs increase by 50-100%), assess renal function, low threshold to admission if poor control, foetal echo with 20 week scan and additional growth scans every 4 weeks from 28 weeks. Can use metformin!
Delivery - recommend elective at 38 weeks (40 if GDM), use continuous foetal monitoring, avoid hyperglycaemia and may use sliding scale insulin
Postnatal - breastfeeding encouraged (most drugs compatible), pre-pregnancy counselling before next pregnancy
Complications of diabetes in pregnancy
Maternal - hypo unawareness (esp 1st T), increased risk pre-eclampsia, higher rates LSCS
Foetal - miscarriage, risk malformation rates, macrosomia (shoulder dystocia) or IUGR, polyhydramnios, preterm labour, still birth
- all reduced by good glycaemic control!
Gestational diabetes
- screen if first degree relative, previous large baby or GDM, BMI >30
- closely monitor glucose and foetal growth
- if levels not controlled by diet and exercise in 1-2 weeks then metformin/glibenclamide or insulin
- 50% will develop T2DM, so give lifelong dietary advice and follow-up
Asymptomatic bacteriuria in pregnancy
UTI
- pregnancy aggravated
- treat aggressively, as sepsis/miscarriage risk
Asymptomatic found in 7% pregnancies, more in diabetes or renal transplant
- high risk pyelonephritis
Screen all women at booking with MSU!
Treat - cefalexin (trimethoprim never in 1st trimester, nitrofurantoin not in 3rd)
Pyelonephritis
- more common as dilatation of upper renal tract in pregnancy
- presents as malaise with urinary frequency OR with temperatures, tachycardia, vomiting, loin pain
- culture blood and urine, then IV abx (cefuroxime) then oral
- if repeated infections, may give low dose amoxicillin
Asthma in pregnancy
Usually remains unchanged/improved by pregnancy (endogenous steroids) but may worsen
- severe/poorly controlled asthma -> IUGR and preterm labour
- medications safe in pregnancy but NOT leukotriene receptor antagonists
Thyroid disease in pregnancy
Normal pregnancy mimics hyperthyroid - raised HR, warm moist skin, slight goitre, anxiety (TSH similar to hCG)
- fertility is reduced by hyperthyroidism (+ miscarriage risk and malformations) - use carbimazole, monitor monthly
- fertility is reduced by hypothyroidism (+ miscarriage risk, anaemia, IUGR) - use levothyroxine and monitor each trimester. Be aware associated postpartum depression.
Infectious disease in pregnancy
Always beware rash - ?rubella, measles or parvovirus B19 - all risk foetal loss or damage
CMV - mild maternal infection but significant effects on foetus - IUGR, microcephaly, hepatosplenomegaly, thrombocytopaenia, jaundice, chorioretinitis
- toddler urine is significant source - limit contact for pregnant mum
HBV - all mothers screened, vaccinate babies of carriers/infected mothers at birth, and serology at 1 year old
Rhesus status
- if Rh-ve mother deliver Rh+ve baby, leak of foetal red cells causes mum to produced anti-D IgG antibodies (isoimmunisation)
- in subsequent pregnancies these can cross the placenta and cause rhesus haemolytic disease
In all Rh-ve mothers, test for D antibodies at 12, 28 and 34 weeks gestation (Kleihauer test)
- if found, give anti-D immunoglobulin
- give anti-D postnatally to all Rh-ve women where baby status is uncertain (incl in miscarriage/abortion after 12 weeks)
Structural abnormalities
- nuchal translucency at 11-14 weeks
- anomaly scan at 18-22 weeks
Lethal abnormalities - anencephaly, bilateral renal agenesis, major cardiac abnormalities, trisomy 13 and 18 - offer second opinion always in FMU.
AFP - alpha-fetoprotein associated with foetal malformations or adverse outcomes
Delay in labour
Due to power (poor uterine contractions, exhaustion), passage (inadequate pelvis), passenger (malposition, malpresentation, large foetus)
In first stage (<0.5cm dilation/hr):
- ensure adequate analgesia and hydration, change maternal position
- ARM and reassess in 2hrs, or if ruptured then oxytocin infusion and reassess in 4hrs (NOT if multip)
In second stage (>2 hours pushing primip, 1 hr multip):
- consider instrumental delivery or LSCS
Maternal collapse assessment and management
Maternal collapse call via 2222
A-E as normal
- displace uterus to relieve pressure from aorta and vena cava and improve venous return to heart
- keep supine, apply left manual uterine displacement
- if no return of circulation after 5 mins CPR in >20 week foetus then LSCS (for mother not baby)
Causes of maternal collapse
Head
- eclampsia, haemorrhage, epilepsy, trauma, vasovagal
Heart
- MI, arrythmia, peripartum cardiomyopathy, congenital heart disease, aortic dissection
Hypoxia
- PE, asthma, pulmonary oedema, anaphylaxis
Haemorrhage
- abruption, uterine atony, genital tract trauma, uterine rupture, uterine inversion, ruptured AA
wHole body and Hazards
- hypoglycaemia, amniotic fluid embolism, septicaemia, trauma, complications of anaesthesia
Pain relief in labour
Non-pharmacological - education, supportive birth partner, acupuncture/homeopathy/hypnosis, TENS in early labour, water birth
Nitrous oxide (Entonox with 50% O2) Pethidine/diamophine Lidocaine pre episiotomy/suturing
Epidural analgesia
Combined spinal epidural CSE
Spinal anaesthesia (for LSCS)
Third stage of labour
Syntometrine decreases third stage time, and incidence of PPH
- not in pre-eclampsia, HTN, liver or renal impairment, heart disease (can precipitate MI)
Or can just give oxytocin if no BP measured in labour.
Indications for IOL
- post-dates (41-42 weeks if <40, <40 weeks if >40yo)
- multiple gestations
- prolonged ROM
- IUGR
- diabetes (40 weeks if diet controlled, 39 if metformin, 38 if insulin, 37 if poor control)
- maternal medical conditions
- pre-eclampsia
- reduced FMs >37 weeks
- intrauterine death
+ maybe maternal request, suspected large for dates
Contraindications
- breech, fetal distress, placenta praevia, cord presentation, pelvic tumour
Bishop’s score
Cervical assessment for planning IOL
- cervical dilation
- length of cervix
- station of head
- cervical consistency
- position of cervic
> 5 is favourable, if >7 should be induction with ARM asap (avoiding prostaglandings)
Methods and complications of IOL
- monitor CTG prior to prostaglandin use
- ARM
- if clear liquor, 2-4 hours mobilisation to allow spontaneous contractions
- if not contracting, start oxytocin in 0.9% saline pump, increasing rate every 30 mins until 4 in 10 contractions
Complications:
- stop if foetal distress or uterine hyperstimulation (>5 in 10 with foetal compromise)
- risky if previous LSCS, risk of scar rupture
- failed induction in 15%
- higher rates of LSCS and instrumental delivery
Indications for instrumental delivery
In 10-15% UK births
- prolonged 2nd stage
- maternal exhaustion
- pushing not possible (medical or neuro)
- suspected foetal distress
- preterm infant <34 weeks
- face or breech presentation
- significant caput
Abandon attempt if no progression with each pull x3 –> LSCS (already consented for!)
Ventouse
Advantages over forceps
- less analgesia needed
- less perineal/vaginal trauma, less pelvic floor damage
- occupies less space in pelvis
BUT
- must be >34 weeks
- more likely to cause foetal trauma (cephalhaematoma, retinal haemorrhage)
- significant maternal effort required
Forceps
Advantages over ventouse
- faster
- less trauma to baby
- can be used for face/breech
- can be used <34 weeks
- less likely to fail
- less maternal effort required
BUT
- more trauma to mother, more painful
(different types for different situations - outlet, rotation, mid-cavity)
Caesarean section
LSCS
In UK, 25% nulliparous women, <5% multips with no previous section
Average hospital stay 2-3 days (24hr min)
Category 1 - crash call, immediate threat to life, aim to deliver <30 mins after decision
Cat 2 - maternal or foetal compromise, not life threatening, 30-60 mins
Cat 3 - semi-elective eg failed IOL
Cat 4 - elective eg breech
Complications
- blood loss
- uterine lacerations (beyond incision)
- bladder/bowel injury
- hysterectomy (0.2%)
- wound infection
- endometritis
- VTE (if emergency CS give 7 days LMWH)
- in future pregnancies, higher risk placenta praevia and accreta, uterine rupture, antepartum stillbirth x2 risk
Puerperium
= 6 weeks after delivery
- normal to pass lochia for 3 days (red blood), then yellow then white for 10 days
- give anti-D within 72hrs if Rh-ve
- teach pelvic floor exercises
- VTE prophylaxis
- discuss contraception - POP any time, COCP at 3 weeks unless breastfeeding, IUD <48hrs or after 4 week, lactation!
- beware pyrexia, infections, endometritis
- mental health - psychosis, depression, mania
Abdominal pain in pregnancy
- preterm labour (1/10mins regular contractions, likely raised fFN fetal fibronectin swabbed from posterior fornix of cervix)
- benign - round ligament/pelvic girdle pain, Braxton-Hicks contractions, idiopathic
- early pregnancy - threatened/inevitable/incomplete miscarriage, ectopic
- late pregnancy - abruption, pre-eclampsia, uterine rupture
- pregnancy-aggravated - fibroid degeneration or torsion, ovarian torsion, UTI/pyelonephritis, constipation/bowel, urine retention
+ anything else! eg appendicitis, renal calculi, intestinal obstruction, ulcers etc
Monitoring of preterm labour
- lifestyle - smoking, stress, rest
- cervical cerclage for incompetence - done pre-pregnancy, in 2nd trimester or if see USS evidence of shortening
- steroids up to 34+6
- MgSO4 up to 34 weeks
- tocolytic agents to inhibit contractions eg nifedipine (not if bleeding/ruptured membranes)
- inform NICU team and prepare for birth
Reduced foetal movements
Should be feeling movements from 17-24 weeks
Reasons for death - pre-eclampsia, placental abruption, infection, hypoxia
Reasons for stillness - high BMI, neuromuscular conditions, polyhydramnios, placenta at front, opiate analgesia/drug use, foetal anaemia, anxious/busy mother
Polyhydramnios
Measured by AFI (amniotic fluid infex)
- poly if >25cm
- risks of abruption, PPH, prolapsed cord, unstable lie, preterm birth
(increased pressure on cervix, enlarged uterus, has to contract more post partum)
- 60% idiopathic, but more likely in diabetes, infection, lithium, immune hydrops, abdo wall defect in baby, upper GI atresia, neural tube defects, TTTS, skeletal abnormalities
- if severe, FMU may give therapeutic amniocentesis
Termination of pregnancy legality
1967 act, need one of these 5 (in reality is mostly c)
A) continuance of pregnancy would involve risk to life of mother
B) termination is necessary to prevent grave permanent injury to physical or mental health
C) pregnancy not exceeded 24th week, and continuance would involve risk of injury to physical or mental health to mother – most come under this
D) pregnancy not exceeded 24th week and continuance would involve risk of injury to physical or mental health of existing children or family
E) substantial risk that if child were born it would suffer such physical or mental abnormality to be seriously handicapped
Two medical practitioners must be in agreement and sign clause before abortion, and Chief Medical Officer is notified of every abortion in UK within 14 days. (if a doctor objects/can’t provide abortion, must pass on care to someone who can)
Methods of TOP
Medical
- 1/2 pills, technically up to 22 weeks but very unpleasant past 12-14
- Mifespristone (anti-progesterone) + Misoprostol (uterotonic, used alone if <7 weeks)
Surgical
- always under GA
- for 7-14 weeks suction currette, 14 onwards mash and suck (from 22 need fetocide first)
- risks - perforation, adhesions (Asherman’s syndrome) so subfertility, infection/endometritis, depression/PTSD
How to read CTG
DR C BRaVADO
Define Risk Contractions Baseline Rate Variability Accelerations Decelerations Overall impressions/outcome
Nausea and vomiting in pregnancy
- usually ~6-20 weeks, in 80%
- should still exclude other causes
- manage in community if systemically well - prochlorperazine, promethazine, metoclopromide (not in young), cyclizine (rare, dirty) + oral hydration, little and often diet advice, support and reassure
Hyperemesis gravidarum
= NVP + 2+ or more ketones in urine, 5% weight loss, electrolyte imbalance
- N+V in pregnancy + dehydration (from reaction to hCG)
- often comorbid UTI, unable to keep food/fluids/antiemetics down
- manage in hospital initially - IV access, check for multiple/molar pregnancy, ABG for lactate, give fluids with maybe added potassium, antiemetics, abx, paracetamol
Rules on abx in pregnancy
- No trimethoprim in 1st trimester
- No nitrofuration in 3rd trimester
- cefalexin ok
Recurrent miscarriage
= loss of 3 or more consecutive pregnancies <24 weeks
- most common in age >35 (and paternal age >40)
Causes
- 50% unexplained
- bacterial vaginosis
- parental chromosome abnormality (balanced reciprocal or Robertsonian translocation)
- uterine abnormality
- antiphospholipid syndrome - give aspirin + LMWH from day of pregnancy test, expert advice
- thrombophilia - LMWH
- alloimmune causes
Management
- referral to specialist clinic
- test all for antiphospholipid antibodies
- thrombophilia screening
- pelvic USS to assess uterus
- karyotype fetal products at 3rd loss
Ectopic pregnancy
- always first differential in women of childbearing age with acute abdominal pain, bleeding or fainting
- symptoms - often none! amenorrhoea, pain (classically unilateral), PV bleeding, diarrhoea, dizziness, shoulder tip pain, collapse, peritonism
- risk from PID or previous surgery, previous ectopic, endometriosis, IUCD, POP, subfertility and IVF, smoking
- 97% tubal, mostly ampulla
Ectopic pregnancy investigations and management
Investigations
- FBC, G+S
- 2x large bore IV cannulas, IV fluids and call senior if unstable
- serum progesterone and hCG
Managment
- expectant - if falling hCG and stable, confirmed location of pregnancy with no foetal heart activity - closely monitor hCG to ensure falling away
- medical - if stable and confirmed location of pregnancy with no foetal heart activity - methotrexate single dose, monitoring hCG levels. Needs reliable contraception for 3mo after!
- laparoscopy
- salpingotomy vs salpingectomy - if contralateral tube is healthy, recommend removing tube (as risk persistent trophoblast with otomy)
Molar pregnancy
= on spectrum of gestational trophoblastic disease
- pre-malignant = molar pregnancy - partial or complete
- malignant = invasive mole, choriocarcinoma, placental site trophoblastic tumour
- molar pregnancies present with PV bleeding, hyperemesis gravidarum, uterus large for dates, sometimes hyperthyroid
- snowstorm appearance on USS
- needs follow up in specialist centre (3 in UK) and histology after surgical evacuation
Benign disease of the vulva
Pruritis vulvae
- caused by general pruritis, skin disease (psoriasis, lichen planus), local infection, allergy, infestation (scabies, lice, threadworm) or vulval dystrophy (lichen sclerosis, leukoplakia, carcinoma)
Bartholin’s cyst and abscess
- blockage of gland secreting lubricating mucus
- initially painless cyst -> extreme pain, swollen red hot labium, needing incision and drainage (need to exclude gonococcus)
Vaginal discharge
Causes
- physiological (pregnancy, puberty, arousal)
- infection (smelly, itchy)
- foreign body (foul smelling eg from tampon)
Always speculum exam and take swabs
- bacterial vaginosis - common, fishy odour, alkalotic pH. Treat with metronidazole PO or clindamycin cream.
- candida/thrush - white cottage cheese, more likely in pregnancy/steroids/COCP. Treat with clotrimazole pessary/cream or fluconazole PO.
- trichomoniasis - vaginitis, bubbly thin fish-smelling discharge, strawberry appearance on cervix. Treat with metranidazole PO.
Cervical ectropion
- red ring around os where endocervical epithelium extends out
- exacerbated by hormonal influence (puberty, COCP, pregnancy)
- prone to bleeding, mucus production, infection
- no treatment unless severe and not pregnant/pubertal - cautery with diathermy if desired
Fibroids
= uterine leiomyomata
- benign smooth muscle tumours, often multiple
- intramural, subserosal, submucosal, pedunculated
- common, especially in older age, Afro-Caribbean women and in Fhx
- oestrogen dependent, so enlarge in pregnancy and COCP, and atrophy after menopause
Presentation
- often asymptomatic
- menorrhagia, fertility problems, pain (torsion), mass
Treatment
- none if minimal symptoms
- GnRH analogue for few months just before surgery (not long term)
- ullipristal acetate 3-6 months
- myomectomy
- uterine artery embolisation (not for retaining fertility)
- hysterectomy - only cure.
Endometriosis
- endometriotic tissue outside uterus (adenomyosis is within myometrium)
- hormonally driven
- common but cause unknown
- presents with PAIN - cyclical + constant, dysmenorrhoea, dyspareunia, dysuria, dyschezia, + subfertility
- classically feel fixed retroverted uterus on bimanual examination, maybe also feel masses
- MRI if bowel involvement suspected, TVS not that useful, laparoscopy with biopsy gold standard
Treatment - COCP, Mirenaa IUS, GnRH analogues, Goserelin if trying to conceive. Laparoscopic removal is mainstay - ablation, excision or coagulative. (hysterectomy last resort)
Pelvic inflammatory disease
= infection of upper genital tract
- usually ascending from STI, uterine instrumentation, or post-partum (can descend from eg appendicitis)
- presents with lower abdo pain (uni or bilateral, constant or intermittent), deep dyspareunia, vaginal discharge, intermenstrual/post-coital bleeding, dysmenorrhea, fever
- cervical excitation on examination
- should swab for chlamydia and gonorrhoea and take MC+S, escalate if acutely unwell
- manage with ceftriaxone IM stat or azithromycin PO stat + doxycycline/metronidazole PO for 14 days
- risk of abscess, Fitz-Hugh-Curtis syndrome, ectopic pregnancy, subfertility
Ovarian cysts
- extremely common, usually physiological, not concerning unless >5cm, symptomatic and imaging shows concerning features
- present asymptomatic, or with chronic dull pain, acute pain on torsion/bleeding, irregular PV bleeding, hormonal effect, abdominal swelling or mass
- investigate with TVS, manage with laparoscopic ovarian cystectomy if causing problems and rescan
Dysmenorrhoea
Painful periods ± nausea or vomiting
- primary = pain without organic pathology, crampy, worse in first days. Due to excess prostaglandins causing uterine contractions. Mefenamic acid during menstruaction, paracetamol, COCP.
- secondary = associated to eg adenomyosis, PID, fibroids, so presents later in life. More constant through period, deep dyspareunia also. Treat cause, hormonal contraception.
Dyspareunia
= pain during sex
- vaginismus - tense muscles, lack of lubrication, treat with counselling/psychosexual therapy. FGM?
- superficial - infection? perineal scar?
- deep - endometriosis, pelvic infection
- dermatographism - urticaria, itch
Premenstrual syndrome
- physical, behavioural and psychological symptoms regularly occurring in luteal phase of menstrual cycle
- symptoms worse when obese, exercise less, improved by hormonal contraception
- diagnose with symptom diary
- treatment - lifestyle before gynaecology referral.
1. exercise, CBT, Vitamin B6, COCP, SSRIs.
2. estradiol patches.
3. GnRH analogue + addback HRT (Goserelin and tibolone)
4. total hysterectomy + bilateral salpingo-oophrectomy
Amenorrhoea
Primary = failure to start menstruating. Investigate in 16yo, or 14yo with no breast development.
Secondary = periods stop for > 6 months for reason other than pregnancy
- Hypothalamic-pituitary-ovarian causes, eg stress, exercise, weight loss
- Hyperprolactinaemia, eg hypo or hyperthyroidism, severe systemic disease, pituitary tumours
- Ovarian causes - PCOS, ovarian tumours, ovarian insufficiency/failure (premature menopause)
Types and causes of amenorrhoea
Primary = failure to start menstruating. Investigate in 16yo, or 14yo with no breast development.
Secondary = periods stop for > 6 months for reason other than pregnancy
- Hypothalamic-pituitary-ovarian causes, eg stress, exercise, weight loss
- Hyperprolactinaemia, eg hypo or hyperthyroidism, severe systemic disease, pituitary tumours
- Ovarian causes - PCOS, ovarian tumours, ovarian insufficiency/failure (premature menopause)
- Uterine causes - pregnancy, Asherman’s syndrome (adhesions after D+C)
Investigations for amenorrhoea
- beta hCG (pregnancy)
- serum free androgen index (PCOS)
- FSH/LH
- prolactin
- TFT
- testosterone level
Oligomenorrhoea
= infrequent periods
- most common at extremes of reproductive life, if in middle years then consider PCOS
Bleeding
Intermenstrual bleeding
- following midcycle fall in oestrogen, or cervical polyps, ectropion, carcinoma, cervicitis, hormonal contraception, IUCD, chlamydia, pregnancy
Postcoital bleeding
- cervical trauma, polyps, cervical/endometrial/vaginal carcinoma, cervicitis, chlamydia
Postmenopausal bleeding
- due to endometrial carcinoma until proven otherwise
- more likely atrophic vaginitis, foreign body, endometrial/cervical polyp, oestrogen withdrawal
Menopause
= time of waning fertility leading up to last period - retrospective as 12 months pre last period
- average UK age 52
Symptoms
- menstrual irregularity
- vasomotor disturbance - sweats, palpitations, flushes
- atrophy of oestrogen-dependent tissues (genitalia, breasts) and skin
- osteoporosis
20% women seek medical help
- check thyroid and psychiatric symptoms
- encourage diet and exercise for symptom relief
- Mirena coil good for menorrhagia
- contraception until >1yr amenorrhoea (>2 if <50yo)
- oestrogen cream for vaginal dryness
Hormone replacement therapy
- many types, given as tablets patches or creams
- if with a uterus, give combines, if no uterus then can have oestrogen-only (otherwise is major risk factor for endometrial cancer)
- does not provide contraception!
- side-effects common, and needs annual check-up (inc breasts and bp) - use lowest effective dose for shortest time possible
Contraindications
- oestrogen-dependent cancer
- past PE
- undiagnosed PV bleeding
- raised LFTs
- pregnant or breastfeeding
- phlebitis
- be wary in Fhx of breast cancer
Alternatives
- can treat individual symptoms - cream for dryness, calcium/vit D/bisphosphonates for osteoporosis, SSRIs for vasomotor symptoms
Contraceptive methods and counselling
Barrier - most effective if used right! - condoms, caps, cervical sponges, femidom, spermicide
‘Natural’ awareness methods - successful if regular cycles and dedicated
Lactational amenorrhoea
Hormonal - effective but health interactions
IUCD/IUS - convenient and effective unless contraindicated
Sterilisation
- ensure not pregnant first!
- if under 16, Fraser guidelines and best interests
IUCD
= copper coil
- change 5-10 yearly
- inhibit fertilisation, implantation and sperm penetration of cervical mucus
- can be used as emergency contraception
Problems
- can be expelled - more likely if nulliparous or distorted by eg fibroids
- PID risk for 21days post insertion
- commonly cause dysmenorrhoea and menorrhagia
- ectopic pregnancy risk
IUS
= mirena coil
- carries levonorgestrel so as well as inhibiting implantation, also reversible endometrial atrophy
- change every 5 years
- makes periods lighter and less painful, lower risk of ectopic or PID than in IUCD
- spotting and heavy bleeding possible for first few weeks following insertion
- cannot be used as emergency contraception
Emergency contraception
- emergency IUCD best, within 120hr UPSI (or just after ovulation). Need infection screen first, and abx cover with azithromycin PO
- ullipristal acetate = EllaOne. Within 120hr, inhibits/delays ovulation. Not in severe asthma, if on antacids or enzyme inducers.
- levonorgestrel, within 72hr UPSI (more effective sooner)
Combined oral contraceptives
COCP
Contraceptive patch
Contraceptive vaginal ring
Contraindications
- VTE/varicose veins
- arterial disease including stroke, TIA, IHD
- migraine with aura
- liver disease
- breast cancer - personal or strong Fhx
- previous pregnancy complications inc pruritis, cholestasis, chorea, or if postpartum/breastfeeding
- hepatic enzyme-inducing drugs
- – no more than 1 of smoker, BMI>30, FHx VTE or arterial disease, immobility, diabetes mellitus, HTN, migraine without aura
Side effects
- oestrogenic - breast tenderness, nausea, weight gain etc
- progestogenic - mood sweings, dryness, reduced libido, acne
- headache
- breakthrough bleed
- need emergency contraception if 3 or more pills forgotten in 1st 7 days and had UPSI
Progesterone only pill
- work by thickening cervical mucus and reducing receptivity to implantation (and inhibit ovulation)
Contraindications
- current breast cancer
- trophoblastic disease
- liver disease
- migraine with aura, stroke, IHD
- SLE with antiphospholipid antibodies
- undiagnosed PV bleed
Side effects
- higher failure rate than COCP
- menstrual irregularities
- risk ectopic pregnancies and cysts
- depression, acne, reduced libido, weight gain
- need emergency contraception if 1 or more POPs missed or taken >3hrs late and UPSI in 2 days following this for levonorgestrel, or >12hrs late for desogestrel
Depot progestogen and implants
IM 12 weekly or 8 weekly dependent on preparation
- can be used up to age 50 as long as no signs of osteoporosis
- weight gain side effect common
- delay in return of ovulation on stopping injections
Progesterone implants
- 3 years effective
- no impact on bone density
Sterilisation
- permanent, irreversible
- no CIs as long as requested by patient and not acting under duress!
- female - laparoscopic under GA. May get much heavier periods after. More failure rates (and increased risk ectopic)
- male - can be as OP under LA, simpler and safer. Need contraception for 3 months (or obtain 2 ejaculates ‘negative’ for sperm)
- reversal 50% success for both, never funded by NHS
Endometrial sampling
= pipelle biopsy
- bedside investigation for postmenopausal bleeding
- cheap, reliable, no need for anaesthesia (but very uncomfortable and need proper technique to get adequate sample)
- sample if TVS USS shows endometrium >4mm
- vacuum cannula to suck in endometrial tissue
- reassure if normal/atrophic
- if re-bleed, or find polyps or necrotic tissue, send for hysteroscopy
- if atypical hyperplasia or carcinoma, send for hysterectomy and BSO
Cervical screening (cytology)
- for sexually active women aged 25-64 (3 yearly 25-50, 5 yearly until 64)
- pre-invasive phase of cancer = CIN, dyskariosis detected by smears
- associated with oncogenic HPV 16, 18, 31, 33. Smoking and immunocompromise + risk.
- if borderline/mild changes, refer for HPV testing, if +ve then colposcopy
- CIN 1 = lower basal third. CIN 2 and 3 = 2/3 or full thickness of epithelium, high risk to develop into invasive squamous carcinoma, so refer to colposcopy regardless of HPV status
Colposcopy
- examination of cervix with binocular colposcope
- visualise cervix, identify transformation zone and paint with 5% acetic acid
- preferentially taken up by neoplastic cells, so white areas abnormal
- punch biopsy to identify CIN or malignancy, or if strong uptake then treat in same appointment with LLETZ (unless pregnant)
Large loop excision of the transformation zone
LLETZ
- under LA during colposcopy, using loop diathermy
- safe and easy to perform, 90% cure
- low grade (CIN 1) regresses spontaneously with no treatment, 6 monthly colposcopy and LLETZ if persistent and HPV +ve
- high grade (>CIN 1) do LLETZ
- 6 months after procedure, smear, and if -ve return to 3 yearly
Complications
- haemorrhage, infection, vaso-vagal symptoms, small risk cervical incompetence (increased with multiple procedures), anxiety!
HPV vaccine
- main risk factor for cervical cancer
- offered to girls in UK aged 12
- against 6 and 11 (anogenital warts) and 16 and 18 (HR HPV)
- no protection once infection has occurred, and do not prevent other cancer causing types
Cervical cancer presentation
- peak incidence 30s and >70s
- risk factors as for CIN (HPV, smoking, immunocompromise)
Presentation
- cervical smear / CIN treatment finding
- post-coital or post-menopausal bleeding
- watery vaginal discharge
- advanced disease - heavy vaginal bleeding, ureteric obstruction, weight loss, bowel disturbance, vesicovaginal fistula, pain
- see irregular cervical surface and abnormal vessels on colposcopy, feels roughened and hard on bimanual, may bleed on contact
Cervical cancer investigations and treatment
Ix
- FBC, U+E, LFTs
- punch biopsy (not LLETZ)
- CT abdo and pelvis for staging
- MRI pelvis for staging + lymph
- examination under anaesthetic? by cystocopy, hysteroscopy, PV/PR exam
Stage I - in cervix only
– local excision (cone biopsy or radical trachelectomy) / hysterectomy / chemoradiotherapay
Stage II - in upper 2/3 vagina
– combination chemoradiotherapy
Stage III - in lower 1/3 vagina or pelvic wall
Stage IV - in bladder/rectum
– palliative chemoradiotherapy
Radiotherapy risks acute bladder/bowel dysfunction, tenesmus, mucositis, bleeding, fistula, vaginal shortening/dryness
Endometrial cancer
- postmenopausal vaginal bleeding!
- usually adenocarcinomas, related to excess oestrogen (obesity, T2DM, HTN, nulliparity, PCOS, late menopause/early menarche, HNPCC, breast cancer, oestrogen-only HRT)
- parity and COCP are protective factors
- TVS endometrial thickness >4mm, then biopsy or hysteroscopy
- treat with total hysterectomy with BSO open or laparoscopically, lymphadenectomy controversial
Ovarian cancer
- leading cause of gynae cancer deaths, as tends to present late with insidious onset of symptoms
- peak 70-80s
- risk increased by nulliparity, early menarche/late menopause, BRCA 1 and 2 mutations, HNPCC
- tubal ligation, pregnancy, breastfeeding and COCP are protective
Presentation
- bloating
- unexplained weight loss, loss of appetite, early satiety
- fatigue
- urinary frequency/urgency
- change in bowel habit
- abdo or pelvic pain
- vaginal bleeding
- pelvic mass palpable, + maybe ascites, pleural effusion
Investigations and management of ovarian cancer
Ix
- FBC, U+E, LFT
- CA125
- TVS USS
- CXR (for lung mets or pleural effusion)
- CT abdo pelvis (staging)
- MRI
- sample ascites or pleural effusion if present to cytology
- treat with full staging laparotomy - hysterectomy, BSO, omentectomy, para-aortic and pelvic lymph node sampling, peritoneal washing and biopsy, then chemo for all after surgery
Vulval carcinoma
VIN see white areas with surrounding inflammation, itchy
- cause often HPV
- surveillance and imiquimod cream
- carcinoma presents as lump, or indurated bleeding painful ulcer
- treat with local incision ± lymphectomy ± radical vulvectomy ± radiotherapy (or chemo if unsuitable for surgery)
Urinary continence
- Storage symptoms – frequency, nocturia, urgency, urinary incontinence
- Voiding symptoms – hesitancy, slow stream, straining, spraying splitting of stream, double void, incomplete emptying, position dependent micturition, retention
Incontinence - stress/urgency/mixed
- discuss diet, caffeine, pregnancies/deliveries, mobility issues, medications
- bladder diary
- stress test, pad test, Q-tip test
- urodynamics for voiding function
- cystometry to look at pressures intravesically vs rectal(abdo) vs detrusor
Treatment of stress incontinence
- behaviour - weight loss, fluid management
- pelvic floor training
- duloxetine SNRI (side effects)
- urethral bulking surgery
- midurethral sling surgery
- mesh NO
- colposuspension
Treatment of overactive bladder
- behaviour - bladder retraining, fluid management
- pelvic floor training
- antimuscarinics (side effects) tolterodine, solifenacin
- cystoscopy
- botox intravesical injection
- neuro-modulation
- detrusor myomectomy
Prolapse
- caused by pregnancy/childbirth, menopause, raised intra-abdominal pressure, congenital collagen deficiency, iatrogenic
- uterine/vaginal prolapse in 50% women, 11% needing surgery
- presents with heaviness, end of day backache, sexual difficulties, urological and defaecatory problems
Treatment
- reassure (pelvic floor)
- ring (pessaries)
- repair (surgery - hysterectomy, anterior/posterior repair, vaginal closure? NO mesh)
Gynae emergencies
Ovarian
- cyst rupture (sudden pain, guarding)
- haemorrhage (sudden pain, anaemia)
- torsion (sudden extreme pain + vomiting +pyrexia, tender mass - need urgent laparoscopy)
Other - infection, acute urinary retention, intestinal obstruction
Fibroids
- prolapsing (labour pain, bleeding, abdo mass and open os)
- degenerating (in pregnancy usually, gradually increasing tenderness)
Acute PID (gradual onset, unwell, dyspareunia, discharge)
Ovarian hyperstimulation (after fertility treatment, ascites, pain, thrombosis)
Bartholins abscess
Pregnancy related - septic miscarriage / ectopic pregnancy
Subfertility causes and investigations
- unexplained
- male factor
- anovulation (Turner’s, surgery/chemo, PCOS, weight loss, hypopituitary)
- tubal factor
- endometriosis
Ix in primary care
- chlamydia screening
- baseline hormonal profile (FSH and LH)
- TSH, prolactin, testosterone, rubella status
- mid-luteal progesterone
- semen analysis
Ix in secondary care
- TVS for masses/fibroids
- hysteosalpingogram
- laparoscopy and dye test (tubal patency)
Assisted reproduction
1st - lifestyle (weight loss, exercise, stop smoking, reduce alcohol, take folic acid, intercourse every 2-3 days not timed!)
- IVF (on NHS for couples with no children, non-smokers, BMI<30, <42yo)
- IVmaturation (eggs matured in lab before ICSI, so avoids hyperstimulation risk eg in PCOS)
- intracytoplasmic sperm injection ICSI
- intrauterine insemination
- donor insemination (if azoospermia and failed sperm retrieval)
- ooplasmic transfer (two mothers)
- percutaneous epididymal sperm aspiration
Ovulation induction
Usually for PCOS
- weight loss or gain
- clomifene citrate (days 2-6) anti-oestrogen
- laparoscopic ovarian drilling
- gonadotrophins (if resistant, rare)
- metformin (controversial, not licensed)
